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RENOWN SOUTH MEADOWS MEDICAL CENTER 10101 DOUBLE R BLVD RENO, NV 89521 April 6, 2012
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observation and interview, the facility failed to implement policies and procedures for cleaning isolation rooms of patients with infections.

Findings include:

On 4/5/12 at approximately 10:00 AM, Housekeeper, Employee #5, was observed cleaning an occupied contact isolation room. The infection control nurse and housekeeping supervisor, Employee #6, were present when the room was cleaned.

The housekeeper, Employee #5, was observed to make the following errors:

1. The housekeeper placed a PDI wipe under the mop to clean the floor. The PDI wipe rolled around under the mop head making insufficient contact with the floor. The housekeeper claimed there was no bleach on the unit so she used the PDI wipe. The mop head was already wet with the appropriate disinfectant floor cleaner and the cleaning of the floor did not require bleach.

2. The housekeeper carried the mop used to clean the isolation room out of the room to the housekeeper's cart for supplies.

3. The mop that was used to clean the floor was also used to clean the lower portion of the patient room walls.

4. The housekeeper pushed debris collected from mopping the floor in the isolation room out onto the periphery of the rug in the hallway.

5. The housekeeper reported she was going to leave a cleaning brush and germicidal solution in the patient's room for use in order to save money.

The housekeeping closet on the third floor unit was observed. There was an empty container of Clorox bleach on the shelf. The housekeeper, Employee #4 acknowledged bleach solution could be obtained from the first floor closet if needed. The housekeeper, Employee #4, was unable to accurately state the exact amount of bleach to use in making a 1:10 solution.

In interviews with the infection control nurse and the housekeeping supervisor, Employee #6, on 4/5/12 at approximately 10:30 AM, they acknowledged housekeeper, Employee #5, did not follow hospital procedure when she used the PDI wipe under the mop, left the isolation room with a potentially contaminated mop, mopped debris from the isolation room room to the rug and not disposing the cleaning brush and solution following use. Both the infection control nurse and the housekeeping supervisor acknowledged housekeeper, Employee #4, was unable to describe the amount of Clorox bleach needed to adhere to their cleaning policy and procedure.

The first floor housekeeping closet was observed and was found to contain a Clorox Bleach dispenser in addition to other disinfecting solutions used to clean rooms.

On 4/5/12, Kevin Johnson the head of environmental services was interviewed. Mr. Johnson was present for part of the housekeeping observation. He reported that bleach solution was available in bottle form in addition to the dispenser on the first floor unit. He acknowledged the housekeeper, Employee #5, did not follow hospital policy when cleaning the isolation room and that she was in need of training.

Review of the hospital policy entitled "Pt Area - patient Room Occupied Isolation" revised 3/12 revealed a sodium hypochlorite solution (1:10 bleach solution) was recommended for C- difficille and PDI wipes for the second step cleaning of high touch areas. The policy and procedure revealed the
Johnny mop used to clean the toilet was to be placed in a small bag and disposed of following use. the policy and procedure revealed walls were to be checked and spot cleaned with a clean microfiber cloth and a germicidal solution.